1Department of Anatomy
Bayero University Kano
*Author of Correspondence, Email: , GSM: +2347036878467

ABSTRACT
Prehypertension is a borderline blood pressure status associated with both higher incident cardiovascular disease as well as higher risk of progression to hypertension. There is a rising burden of hypertension and prehyperension globally. This study aims to estimate the burden of prehypertension in Nigeria. Online searches of Google Scholar, PubMed and African Index Medicus were conducted and studies selected based on predefined criteria. 64 studies consisting of 62396 individuals conducted between 2011 and 2021 were included in the meta-analysis. The pooled prevalence of prehypertension in Nigeria was found to be 33%
(95% CI: 30%-36%) translating to 39.6 million adult Nigerians. Males have higher prehypertension prevalence of 37.4% (95% CI: 33%-42%) than females with prevalence of 31.3% (95% CI: 27.2%-35.5%). The regions with the lowest prehypertension prevalence are North-Central and South-East each at 31%. The region with the highest prevalence of prehypertension is North-East at 62%. The pooled prevalence in rural settings is 33% whereas the pooled prevalence for urban settings is 32%. Differences between sexes, regions and between rural and urban settings were not statistically significant. In conclusion, the burden of prehypertension in Nigeria is high and represents a future burden of hypertension and other cardiovascular events

Keywords: Pehypertension, Prevalence, Nigeria

1 INTRODUCTION

Prehypertension (PHTN) is a borderline high-risk blood pressure status. It is defined as systolic Blood Pressure(BP) of 120-139mmHg and/or diastolic BP of 80-89mmHg(National High Blood Pressure Education Program, 2004). Prehypertension is associated with about fourfold increased risk of developing hypertension compared to normotensive individuals with 10% annualized progression rate to hypertension(Vasan et al., 2001). In addition to this high risk of conversion to hypertension, prehypertension is associated with 200% increase in cardiovascular disease incidence compared to blood pressure less than 120/80mmHg(National High Blood Pressure Education Program, 2004).
There is worldwide increase in the burden of high blood pressure. In a pooled analysis of 1479 studies from 174 countries including 19.1 million participants, there were 594 million people with high blood pressure in 1975. This number increased to 1.13 billion people in 2015 with the increase largely in developing countries. 88% of mortality attributable to high BP is now in developing countries (NCD Risk Factor Collaboration (NCD-RisC), 2017).
In a meta-analysis of 242 322 individuals from 11 countries including Nigeria, prevalence of prehypertension was 38% (Guo et al., 2012). In a recent meta-analysis of 9 studies conducted in Nigeria between 1995 to 2020 and consisting of 16, 241 individuals, the prevalence of prehypertension was found to be 30.9% (95% CI: 22.0-39.7). However, the analysis involved studies conducted in only 4 of the 6 geo-political zones of the country. In addition, no sex-specific prevalence of prehypertension was reported. (Adeloye et al., 2021). This study aims to determine the sex-specific prevalence of prehypertension across the 6 geo-political zones as well as in urban and rural settings of Nigeria.

2 METHODOLOGY

2.1 Study Area

Nigeria is a western African nation with an area of 923,769 sq km, home to more than 250 ethnic groups(Udo et al., 2020). It has 36 states and a capital divided into 6 geo-political zones or regions. The estimated population in 2021 is 211.4 million. 43.4% of the population are under the age of 14 years. 53.9% of the population are between the ages of 15 and 64 years. Only 2.8% of the population are above the age of 65 years (UNFPA - United Nations Population Fund, 2021). Figure 2.1 shows the map of the geopolitical zones of the country.

Geo-Political Zones in Nigeria

Figure 2.1: Geo-Political Zones in Nigeria

2.2 Inclusion and Exclusion Criteria

Included in this review are studies carried out in Nigeria which:

  1. have study subjects > 18 years of age
  2. are community-based observational and interventional
  3. defined prehypertension as systolic Blood Pressure(BP) of 120-139mmHg and/or diastolic BP of 80-89mmHg.

Excluded from this review are studies

  1. conducted in individuals < 18 years
  2. conducted in pregnant women
  3. that did not report prevalence of prehypertension
  4. that are hospital-based.

2.3 Studies Search Strategies

Online databases used were Google Scholar, PubMed, Global and African Index Medicus. Search words and phrases used were: ‘prehypertension,’ ‘pre-hypertension’ and ‘hypertension.’Searches were repeated for each word with the name ‘Nigeria.’

2.4 Data Extraction and Analysis

Extracted information from the studies included prevalence of prehypertension, state and region of the study, study year, mean age and sex composition of the study participants. Random Effects Model for pooling prevalences and Mixed Random Effects Model for meta-regression were fitted using inverse variance method with correction of pooled estimate and its variance using Sidik-Jonkman’s estimator for between study heterogeneity. Analyses were done in R statistical environment for statistical computing, version 4.1.0 (R Core Team, 2021)

3 RESULTS

3.1 Search Results

Figure 3.1 shows the results of the search strategy.

Figure 3.1: Results of the Search

3.2 Characteristics of the Included Studies

64 studies consisting of 62396 individuals met the inclusion criteria and are included in the meta-analysis. The studies were conducted between 2011 and 2021. There were 22 studies from the south-west region, 16 studies from the south-south, 11 studies from south-east, 9 studies from the north-central, 5 studies from the north-west and 1 study from the north-east region. 4 studies were conducted in more than 1 region. 18 were conducted in the rural areas, 47 in urban areas. 3 studies were conducted in both rural and urban areas and did not report separate data for the two settings.
The reported mean age of the studies’ subjects ranged from 31in a north-central study conducted in both urban and rural areas to 55.2 in a south-west study also conducted in both urban and rural settings (Figure 3.2

Number of Included Studies by Region and Setting

Figure 3.2: Number of Included Studies by Region and Setting

Mean Age and Number of Subjects in the Included Studies by Region

Figure 3.3: Mean Age and Number of Subjects in the Included Studies by Region

3.3 Fitting the Meta Analytic Model

Random Effects Model was fitted using inverse variance method with correction of pooled estimate and its variance using Sidik-Jonkman’s estimator for between study heterogeneity. Prevalences are tranformed using arcsine transformation. Figure 3.4 shows the forest plot of the model.

forest plot

Figure 3.4: forest plot

The overall pooled prevalence of prehypertension in Nigeria is 33% (95% CI: 30%-36%). According to the latest data by UNFPA - United Nations Population Fund (2021), this translates to estimated 39.6 million adult prehypertensive individuals in Nigeria. The P value for the random meta analytic model is <0.001. The estimated total between studies heterogeneity(tau2) = 0.02(S.E = 0.003). I2 = 98.5%. Test for Heterogenity showed Q(df= 67) = 3540, p-value<0.001 indicating substantial heterogeneity between the included studies.

3.4 Diagnostics of the Meta Analytic Model

Figure 3.5 shows radial plot of the model with no obvious outlier. This is confirmed by the influence analysis in figure 3.6.

radial plot of the model

Figure 3.5: radial plot of the model

Influence analysis of the model

Figure 3.6: Influence analysis of the model

3.5 Sex-Specific Prevalences of Prehypertension in Nigeria

As shown in figure 3.7, males have higher prehypertension prevalence of 37.4% (95% CI: 33%-42%) than females with prevalence of 31.3% (95% CI: 27.2%-35.5%). The difference is not statistically significant (P = 0.052)

Prevalence of Prehypertension in Males and Females

Figure 3.7: Prevalence of Prehypertension in Males and Females

3.6 Prevalence of Prehypertension in Nigeria by Geo-political Region

Figure 3.8 shows pooled prehypertension prevalences by geo-political zones in Nigeria. The regions with the lowest prehypertension prevalence are North-Central and South-East each at 31%. The region with the highest prevalence of prehypertension is North-East at 62%. The P value of the model is 0.130 indicating lack of statistically significant difference in prevalence of prehypertension across the 6 geo-political regions in the country.

Forest Plot and Map of prevalence of Prehypertension by region

Figure 3.8: Forest Plot and Map of prevalence of Prehypertension by region

3.7 Difference in Prevalence of Prehypertension between Urban and Rural Settings in Nigeria

As figure 3.9 shows The pooled prevalence in rural settings is 33% whereas the pooled prevalence for urban settings is 32% The difference is not statistically significant (P = 0.799)

forest plot of prevalence by rural and urban settings

Figure 3.9: forest plot of prevalence by rural and urban settings

4 DISCUSSION

The pooled estimate of prehypertension prevalence found by this study (33%) is similar to the prevalence of 30.9% found by Adeloye et al. (2021). However, the estimate of this meta-analysis is more precise as evidenced by its 95% Confidence Interval (30%-36%) compared to the Confidence Interval of the estimate by Adeloye et al. (2021) (22.0%-39.7%). The reason for this disparity in precision is explained by the difference in the number of studies and individuals included in the two meta-analyses; our analysis involves larger number of studies and individuals explaining the higher precision of our estimate. It is of note that prehypertension and hypertension have almost the same prevalence (Adeloye et al., 2021). This essentially means that two-thirds of adult Nigerians have abnormal blood pressures and are at high risk of developing endpoint cardiovascular events like stroke, coronory heart disease and chronic kidney disease.
The higher prevalence of prehypertension in males compared to females found in this study is consistent with global trend as found in another meta-analysis of published literature world-wide(Guo et al., 2012).
Figure 4.1 shows the burden of prehypertension in Nigeria compared with prevalences in England, Canada (Joffres et al., 2013), Ghana (Dosoo et al., 2019), India (Tripathy et al., 2017), China (Jin et al., 2013), Iran (Afsargharehbagh et al., 2019) and Nepal (Huang et al., 2019).

Prevalence of Prehypertension in Selected Countries

Figure 4.1: Prevalence of Prehypertension in Selected Countries

5 SUMMARY AND CONCLUSION

33% (95% CI: 30%-36%) of adult Nigerians or 39.6 million adult Nigerians have prehypertension. Males have higher prehypertension prevalence of 37.4% (95% CI: 33%-42%) than females with prevalence of 31.3% (95% CI: 27.2%-35.5%). The regions with the lowest prehypertension prevalence are North-Central and South-East each at 31%. The region with the highest prevalence of prehypertension is North-East at 62%. The pooled prevalence in rural settings is 33% whereas the pooled prevalence for urban settings is 32%. Differences between sexes, regions and between rural and urban settings were not statistically significant. In conclusion, the burden of prehypertension Nigeria is high and represents a future burden of hypertension and other cardiovascular events

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